A Sensory-Motor Approach to CAS and Related Motor Speech Disorders: Why and How

Posted by Deborah Grauzam on

This presentation is going to be held at the Texas Speech-Language & Hearing Association 2017 Annual Convention, Thursday. Feb. 23, noon-1:30 p.m.

Author: Renee Roy Hill, MS, CCC-SLP

Abstract:

Discuss treatment of clients diagnosed with apraxia of speech and related motor speech disorders. Explore 1) Childhood Apraxia of Speech 2) Related Motor Speech Disorders 3) Van Riper’s Phonetic Placement Approach 4) the importance of tactile and proprioception in shaping speech movements for speech, 5) shaping placement of the articulators using tools.

Learning outcomes: 

  1. Participants will be able to list at least three characteristics of Childhood Apraxia of Speech and Dysarthria.
  2. Participants will be able to list at least two goals of a tactile treatment approach.
  3. Participants will be able to implement three phonetic placement methods.

Summary: 

Children with motor based speech disorders such as Dysarthria and Childhood Apraxia of Speech (CAS) present with a speech sound disorder in which precision and consistency of movements underlying speech are impaired. CAS may impact both non-speech and speech movements. CAS may also coexist with disorders of muscle strength and tone such as dysarthria. As infants and toddlers, children with CAS may have limited babbling, limited expression, but seemingly typical receptive skills. Older children with CAS may have poor oral imitation skills, erratic speech sound errors, and lack of a verse phonemic repertoire (Kaufman 2013).  Unfortunately, there is no specific, validated list of diagnostic features of CAS which differentiates this disorder from other types of speech sound disorders (ASHA, 2007), however the research is emerging. 

This presentation will attempt to identify key diagnostic features of both CAS and Dysarthria and discuss when Oral Placement Therapy (OPT) may be beneficial.  While it is always the goal to work on verbal output and speech production, some children with CAS have such severe motor planning issues, or co-morbid muscle based issues that they are non-verbal, or have very limited verbal output. Tactile cueing techniques such as PROMPT (Grigos,2010), or The Kaufman Speech Praxis Therapy (Kaufman, 2007) may prove positive results for some children; however others may need even more work on the sensory-motor system to gain foundational skills necessary for speech (Kaufman, 2007). Kaufman suggests that in order for these therapies to be successful, the child must be able to imitate, sit and attend, and execute gross motor movements on command. In addition, oral motor weakness should not be the primary disorder. For these children, sensory integration, oral motor stretching and toning and speech sound shaping may be needed (Kaufman 2007). There is no question that working on oral-motor skills should not be done is isolation of speech production when dealing with apraxia (Marshalla, 2000), but rather as Oral Placement Therapy (OPT) which is a term suggested by Bahr and Rosenfeld Johnson (2010.)

OPT is a modern extension of Phonetic Placement Therapy (Van Riper, 1954) and The Feedback Model (Mysak, 1971). It is based on a very common sequence (Bahr 2001, Crary 1993, Hayden 2004, Marshalla 2004, Rosenfeld Johnson 1999, 2009, Young and Hawk 1955):   

  • Facilitate speech movement with the assistance of a therapy tool (ex. horn, tongue depressor) or a tactile-kinesthetic facilitation technique (ex. PROMPT facial cue);
  • Facilitate speech movement without the therapy tool and/or tactile-kinesthetic technique (cue fading);
  • Immediately transition movement into speech with and without therapy tools and/or tactile-kinesthetic techniques.

For children with motor speech disorders, this sequence can be helpful if the child cannot form the necessary placement of the articulators to produce sounds. Repetition and reinforcement is helpful based on motor learning theory (Hammer, 2007; Mysak 1971.) To improve speech, one must work on speech (Jakielski, 2007); however one must consider those children who have very limited verbal output (Merkel-Walsh, 2012).

The concept of “bridging” which is movement to speech based on muscle memory is an effective therapy technique (Roy-Hill, 2013). For example if a child has limited lip rounding to produce a /w/ , blowing bubbles can be used to reinforce lip rounding through tactile cueing, and as soon as movement is noted the tool is faded (Van Riper 1958) and speech sound drills can begin.

Clinicians must use evidenced based practice (EBP) to determine therapeutic treatment (ASHA, 2005). It is important to remember that EBP is not only limited to double blind studies, but an “approach in which current, high-quality research evidence is integrated with practitioner expertise and client preferences and values into the process of making clinical decisions (ASHA, 2007). Client progress and clinical data are important factors when determining treatment, and certainly the Phonetic Placement Approach (Van Riper , 1957) has been widely documented in the field of speech pathology. In addition, sensory-motor and oral tactile teaching techniques have clinical data to support their use (Bathel, 2007; Bahr & Rosenfeld-Johnson, 2010). Through muscle and motor based placement skills , therapists can effectively improve speech clarity in children who present with CAS. 

References:

American Speech-Language-Hearing Association. (2007). Childhood apraxia of speech [Technical report] available from www.asha.org/policy

Bahr, D., Rosenfeld-Johnson, S. (2010). Treatment of Children With Speech Oral Placement Disorders (OPDs): A Paradigm Emerges. Communication Disorders Quarterly, XX(X), 108.

Lof, G.L. (2007). Reasons why non-speech oral motor exercises should not be used for speech sound disorders. Presentation at the ASHA Annual Convention, Boston, MA. Nov. 17.

Roy-Hill, R. (2013). A Sensory-Motor Approach to Apraxia of Speech and Related Motor Speech Disorders [Live presentation].

Van Riper, C. (1958, 1954, 1947) Speech Correction: Principles and Methods. Englewood Cliffs: Prentice-Hall.

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Brain Stem Stroke: A Case Study

Posted by Deborah Grauzam on

This case study was originally posted in Advance for Speech & Hearing on November 14, 2016. Retrieved from http://speech-language-pathology-audiology.advanceweb.com/Features/Articles/Brain-Stem-Stroke-A-Case-Study.aspx

Author: Gabrielle Zimmer, MS, CCC-SLP

Brain Stem Stroke: A Case Study

Rebuilding communication one subsystem at a time.

Where do you start when a client understands everything that is said but has no way to communicate back to you? He cannot speak, gesture or write. How can you improve his quality of life?

As speech-language pathologists in the outpatient department at Kessler Institute for Rehabilitation, we frequently encounter challenging situations and provide treatment for medically complex adults who have suffered acquired and traumatic brain injuries (TBIs). To maximize each client’s potential, collaboration with an interdisciplinary team, including physicians, therapists and other specialists, is crucial. The implementation of a variety of treatment approaches based on the individual needs of the client is also critical.

An example of a complex case in which collaboration was necessary is the case of Ben, a 38-year-old male who began feeling right upper extremity twitching and slurred speech. This evolved and progressed and an MRI revealed a severe brainstem stroke. Ben was ultimately diagnosed with Locked-In Syndrome. He was unable to move any part of his body, although his receptive and expressive language and cognition remained entirely intact. He remembers hearing and understanding all that was being said at his bedside, but he was unable to express himself in any way with the exception of eye blinking. Ben recounted his inability to make requests such as to turn on the fan, feed him ice chips or scratch an itch.

Familiar Voice

Ben completed acute inpatient rehabilitation at Kessler and progressed to a state in which he could move his neck and to a small degree his mouth, lips and tongue. By using the eye gaze access feature of a high technology augmentative and alternative communication (AAC) speech generating device, Ben was able to demonstrate to his family members for the first time since his stroke that “he was in there.” This allowed him to communicate his wants and needs, ask questions and express concerns. He was an excellent candidate for an AAC device, but strived to speak in his own voice. Ben achieved his swallowing goals and was beginning to target phonation when he was discharged from inpatient therapy and transitioned to my care in the outpatient department.

When Ben started outpatient therapy, he had significantly reduced breath support, severely reduced tongue, lip, cheek and jaw movement, and was aphonic and unintelligible. He had difficulty changing his facial expressions to convey emotion and was unable to manage his saliva. He required 24/7 supervision and assistance and was unable to verbally communicate his basic wants and needs. Initially, I trialed traditional approaches to improve articulatory movement as well as voice exercises but quickly felt like we were hitting a wall. I felt it was necessary to break down and target each speech subsystem to maximize his abilities.

Tactile Approach

I sought an evaluation from an otolaryngologist who specializes in voice disorders to examine the integrity of his vocal cord movement which proved to be within normal limits. The difficulty appeared to be with the coordination of inhalation and exhalation for productive voicing as well as a resonance disorder due to limited velar movement. Volitional diaphragmatic breathing was challenging and most of his air was lost through his nasal cavity.

Knowing that his vocal cords were functioning properly was promising for the goal of achieving consistent voicing going forward. We used a spirometer for visual feedback and to target consistent volitional inhalation and exhalation for speech. Additionally, we consulted with a prosthodontist to further examine Ben’s palatal movement and to assess his candidacy for prosthesis. Ben was deemed a viable candidate and use of the palatal lift helped improve voicing and increased his volume. Now that voicing was becoming more consistent and breath support was improving, our goals shifted to articulatory movement and intelligibility.

Initially, Ben attempted to mouth single letters and words for lip reading. With such poor movement of his cheeks, lips and tongue, success was inconsistent and extremely frustrating for both Ben and his family. A tactile approach was deemed necessary for this case. I implemented two excellent therapeutic interventions – the Beckman Oral Motor Protocol and oral placement therapy with Talk Tools. The Beckman Oral Motor Protocol provided assisted movement to activate muscle contraction and movement against resistance to build strength and increased control of movement for the lips, cheeks, jaw, and tongue.

This was done in conjunction with a variety of hierarchical oral placement therapy techniques with Talk Tools, such as the jaw grading bite block, bubble blowing, horn blowing, velar grading and straw hierarchies, among others.

Improved Articulatory Movement

The initial tactile-kinesthetic feedback was crucial and contributed to improved articulatory movement. All oral placement tasks were paired with functional speech tasks. Ben began to increase intelligibility starting at the single word level, progressed to the basic phrase level and subsequently advanced to the sentence level. In addition, although Ben was tolerating a regular solid diet with thin liquids, he had self-established habitual patterns to compensate for his limited tongue and lip movement. The treatment approaches that were initially sought to improve his articulatory movement for speech simultaneously improved his feeding and swallowing function as well.

Ben progressed from an aphonic state to demonstrating increasingly controlled respiration for consistent phonation at the conversation level. Focus shifted to improve volume, pitch and vocal quality. His articulatory movement was severely limited, and he improved to the point where he produced intelligible sentences. Carryover was targeted outside of the speech therapy treatment room with collaboration between his physical and occupational therapists. He targeted speech goals to maintain phonation and intelligibility in different positions such as standing upright, lying on his back and during facilitated movement.

This same person who initially relied on an AAC device was now able to gradually participate in conversation using his own voice and his personality emerged. I began to learn about Ben’s interests, such as his skill at trivia, opinions on television shows and sarcastic sense of humor. He achieved major milestones, which included his abilities to participate and self-advocate in doctors’ appointments, hold conversations with his wife out to dinner and contribute to group conversation. His independence increased and required less caregiver support as he could call for help if needed.

Maximizing Abilities

In a complex case like Ben, utilizing a variety of treatment approaches was crucial to his progress and success. It is important to create individualized treatment programs that are comprehensive and functional for the client. The key to maximizing the client’s abilities is maintenance of well-rounded continuing education, implementation of strong evidence-based practice, collaboration within an interdisciplinary rehabilitation team and daily completion of a home exercise program for carryover outside of the therapy setting. This is in combination with time and dedication from the client and their support system. Ben said it best, “You can sit back and wait for a miracle, or you can make one happen. Let’s make a miracle!”

Resources

1: Beckman, D.A., (1994, Rev. 2010). Beckman Oral Motor Assessment and Intervention. Published by Beckman & Associates, Inc., 620 N Wymore Rd, Suite 230, Maitland, Florida 32751-4253. www.beckmanoralmotor.com

2: Rosenfeld-Johnson, S. (2014). A Therapist Guide to Rehabilitative Feeding and Speech Techniques for Teens and Adults: TalkTools, Charleston, SC.
Gabrielle Zimmer, MS, CCC-SLP is a speech-language pathologist and clinical specialist at Kessler Institute for Rehabilitation in West Orange, New Jersey.

Top-ranked by U.S.News & World Report for the 23rd consecutive year, Kessler Institute is the only rehabilitation hospital in New Jersey to be named to the prestigious list of “America’s Best Hospitals” and is the leading center of its kind in the East.

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Tongue Ties and Speech Sound Disorders: What Are We Overlooking?

Posted by Deborah Grauzam on

“The conversation for tongue tie in the speech pathology community is growing louder among some groups of speech-language pathologists (SLPs) (ASHA Leader, 2015). An ASHA literature search has suggested a correlation between tongue ties and difficulty producing lingual alveolar phonemes (Merkel-Walsh & Jahn, 2014). Furthermore, Eschler, Klein, and Overby (2010) indicated that SLPs’ diagnostic criteria, treatment, goals, and discharge criteria for ankyloglossia differ depending on comorbid behavior (i.e., SSDs or feeding/swallowing difficulty).

Recently, there is a rise in the identification of posterior tongue ties in infants who are having trouble feeding and toddlers/adolescents who are exhibiting continuous speech sound errors despite years of speech-language pathology services. Posterior ankyloglossia is characterized by a thickened frenulum (Type III) or a submucosal frenulum visualized as a flat, broad mound absent of any typical protruding frenular tissue, and restricts movement at base of tongue (Type IV) (Kutlow, 2011).”

Meaux, A., Savage, M., & Gonsoulin, C. presented the poster “Tongue Ties and Speech Sound Disorders: What Are We Overlooking?” at the 2016 Annual ASHA Convention, November 17-19 in Philadelphia, PA.

View the full poster here

Authors: Ashley Meaux, PhD, CCC-SLP, Meghan Savage, PhD, CCC-SLP, & Courtney Gonsoulin, MA, CCC-SLP

TalkTools | Tongue Ties and Speech Sound Disorders

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Diet-Shaping for Self-Limited Diets in Children With a Diagnosis of Autism Spectrum Disorder

Posted by Deborah Grauzam on

This article was initially presented at the 2016 Annual ASHA Convention, Thursday, November 17, 2016, 4:30-5:30 PM. It is available in video in full on Facebook: Part 1 / Part 2

Authors:

Robyn Merkel-Walsh MA, CCC-SLP

Lori Overland MS, CCC-SLP/C-NDT

Learner Outcomes:

1. Participants will have an improved understanding of the etiology of a self-limited.

2. Participants will be able to demonstrate understanding of a home-based diet.

3. Participants will be able to comprehend the concept of diet-shaping.

Discussion of Topic:

The CDC (2015) reports, that Autism Spectrum Disorder (ASD) impacts 1 in 68 children in the United States. In “cluster” states such as New Jersey, as many as 1 in 28 boys are affected.

Children with ASD often present with comorbid feeding issues. There is empirical evidence and an overall scientific consensus supporting an association between food selectivity and ASD (Marí-Bauset Zazpe, Mari-Sanchis, Llopis-González & Morales-Suárez-Varela, 2014). Problems with eating often occur before the actual diagnosis of ASD, and clinicians may often be alerted to the disorder when eating problems, nutritional concerns and gastrointestinal problems occur (Beckman & Cole-Clark, 2015).

Studies show that up to seventy percent of children with ASD are selective eaters and up to ninety percent have feeding problems (Volkert & M Vaz, 2010). Children with ASD are significantly more likely to refuse foods based on texture/consistency (77.4% vs 36.2%), taste/smell (49.1% vs 5.2%), mixtures (45.3% vs 25.9%), brand (15.1% vs 1.7%), and shape(11.3% vs 1.7%), (Hubbard, Anderson, Curtin, Must & Bandini,2014). Researchers at Marcus Autism Center and the Department of Pediatrics at Emory University School of Medicine conducted a comprehensive meta-analysis of published, peer-reviewed research relating to feeding problems and autism. Examination of dietary nutrients showed significantly lower intake of calcium and protein and a higher number of nutritional deficits overall among children with ASD (Korschun & Edwards, 2013). Feeding challenges in the Speech-language pathologists receive referrals for feeding issues in ASD both before and after diagnosis (Keen. 2008).

Applied Behavioral Analysis (ABA) has the most empirical research in treating ASD to date. Behavior analysis is a scientifically validated approach to understanding behavior and how it is affected by the environment (Lovaas & Smith, 1989). It has been endorsed by a number of state and federal agencies, including the U.S. Surgeon General and the New York State Department of Health (Iovannone, Dunlap, Huber, & Kincaid, 2003). Research has shown that ABA therapy is effective at increasing appropriate behaviors and decreasing inappropriate behaviors (Kodak & Piazza, 2008). Therefore, it is reasonable to believe the principles on which ABA techniques are based can help with feeding issues (Volkert & M Vaz, 2010). The problem is that behavioral therapies however, do not often take into account the complexity of the sensory-motor system or medical issues, and how they relate to self-limited diets in children with ASD. Behavioral components may be essential in a feeding program; however, they should be implemented in conjunction with a sensory-motor approach to prove the most positive outcomes.

An infant’s first “job” in life is self-regulation and modulating arousal. These hard-wired synergies impact the sensory-motor system and oral-motor development (Overland & Merkel-Walsh, 2013). Many children with autism have significant issues with arousal and self-regulation which drives behavioral responses (Barthels, 2014.) Many children with autism also have qualitative differences in motor skills, especially with posture and alignment. (Teitelbaum, 1998). These differences in motor skills may also impact the motor skills for safely handling food. Therefore, when an individual with autism is referred to a speech-language pathologist (SLP) for self-limited diet, a comprehensive feeding assessment is required, including: review of child’s medical status; gross, fine, and oral-motor development; nutritional status; and sensory processing (Arvedson & Brodsky, 2001). For example, 59 percent of autistic children who were undergoing endoscopy for GI symptoms had carbohydrate digestive abnormalities, compared with only 11 percent in unaffected children undergoing endoscopy for GI symptoms (Beckman & Cole-Clark, 2015). Issues that affect the variety in the diet may not be behavioral. Since the sensory and motor systems cannot be separated (Morris & Klein, 2000), it is very important to task analyze the child’s motor skills and how they relate to feeding before assuming that a self-limited diet is purely behavioral (Beckman & Cole-Clark, 2015; Merkel-Walsh & Overland, 2016).

Sensory processing issues can also contribute to feeding disorders (Twachtman-Reilly, Amaral, & Zebrowski, 2008). Sensory processing refers to the ability to receive messages from the senses, interpret and organize the information in order to turn it in to an appropriate motor or behavioral response. Not all children with sensory processing disorders have autism but more than ¾ or as many as 90% of children with a diagnosis of autism have some degree of sensory processing disorder (Schoen, Miller, Brett-Green & Nielsen, 2009). Children with sensory regulation disorder may not be able to organize themselves for feeding. Those with oral sensory issues may not feel the food in their mouths, or they may be overly sensitive to the feeling of the food in their mouths. They may not feel hunger or satiation. Sensory defensiveness produces a neurochemical reaction of fear that quickly becomes a hardwired automatic response. The nervous system triggers a “fright-flight-fight” response even if it is irrational (Merkel-Walsh & Overland, 2016). In addition, once a behavior is inadvertently reinforced, the behavior will reoccur (Brophy, 2013). Children with autism are at a higher risk for these problems, because many children with autism engage in ritualistic behaviors. Seemingly well-meaning parents and therapists may not realize that by reacting to food refusals they are actually increasing the chance for this behavior to reoccur (Brophy, 2013; Merkel-Walsh & Overland, 2016).

In clinical practice the speech-language pathologist needs to look at how the child with ASD reacts to touch of the extremities, the face, and oral cavity as well as oral habits such as teeth grinding, mouthing objects and eating items other than foods. A diet analysis is needed to assess if the child has intolerances to certain tastes, temperatures and textures. This will establish the child’s home base and provide a starting point for diet expansion. The therapist must look at the underlying oral sensory-motor skills to support safe, effective nutritive feeding (Merkel-Walsh & Overland, 2016).

In conclusion, children with ASD are prone to self-limited diets. In order for a speech and language pathologist to thoroughly assess and treat this disorder, the therapist must be in tune to the sensory-motor system and design a treatment plan based on the home base, and systematically and sequentially via diet- shaping.

References:

Arvedson, J. C. & Brodksy, L. (2001). Pediatric swallowing and feeding: Assessment and management (2nd Ed.). Albany, NY: Singular.

Barthels, K. (2014). There is always a reason for behavior: is it sensory or is it behavior? (Live presentation), New York, NY.

Beckman, D. & Cole-Clark, M. (2015). Diet texture transition for individuals with autism. American Speech Language Hearing Association, Denver, CO. Retrievable: http://www.beckmanoralmotor.com/media/Diet-Texture-Progression-for-Individuals-with-Autism-ASHA.pptx

Brophy, N. (2013). Behavior plan implementation in the classroom. (Power point slides), Ridgefield, NJ.

Center for Disease Control (2015). Autism Spectrum Disorders (ASDs). Retrieved from http://www.cdc.gov/ncbddd/autism/data.html

Fisher, A. G., Murray, E. A., & Bundy, A. C. (1991). Sensory integration: Theory and practice. Philadelphia, PA: F. A. Davis.

Gisel, E. G. (1994). Oral-motor skills following sensorimotor intervention in the moderately eating impaired child with cerebral palsy. Dysphagia, 9, 180-192.

Hubbard, K.L., Anderson, S.E., Curtin, C. Must, A. & Bandini, L.G. (2014). A comparison of food refusal related to characteristics of food in children with autism spectrum disorder and typically developing children, Journal of the Academy of Nutrition and Dietetics, Vol.114 (12), pp.1981-1987.

Iovannone, R. et al. (2003). Effective educational practices for students with autism spectrum disorder. Focus on autism and other developmental disabilities, 10883576,18,3.

Keen, D.V. (2008). Childhood autism, feeding problems and failure to thrive in early infancy, European Child & Adolescent Psychiatry, Vol.17 (4), pp.209-216.

Korschun, H., & Edwards, C. (2013.) Retrieved from http://www.news.emory.edu/stories/2013/02/autism_nutritional_deficits/

Kodak, T. & Piazza, C.C. (2008). Assessment and behavioral treatment of feeding and sleeping disorders in children with autism spectrum disorder. Behavior Modification, 33: 520-536.

Lovaas, O. I. & Smith, T. (1989). A comprehensive behavioral theory of autistic children: Paradigm for research and treatment. Journal of Behavioral Therapy and Experimental Psychiatry, 20, 17-29

Marí-Bauset, S., Zazpe, I., Mari-Sanchis, A., Llopis-González, A. & Morales-Suárez-Varela, M. (2014). Food selectivity in autism spectrum disorders, Journal of Child Neurology, 2014, Vol.29 (11), pp.1554-1561.

Merkel-Walsh, R. & Overland, L.L. (2016). Self-limited diets in children with a diagnosis of autism spectrum disorder. Oral Motor Institute. Vol 5, Monograph 7. Retrieved from: http://www.oralmotorinstitute.org/mons/v5n1_walsh.html

Morris, S. E., & Klein, M. D. (2000). Pre-feeding skills: A comprehensive resource for mealtime development. San Antonio, TX: Therapy Skill Builders.

Overland, L.F. & Merkel-Walsh, R. (2013). A sensory-motor approach to feeding. Charleston, SC. TalkTools.

Schoen, S., Miller, L.J., Brett-Green, B.A. & Nielsen, D.M. (2009). Physiological and behavioral differences in sensory processing: a comparison of children with autistic spectrum disorder and sensory modulation disorders, Frontiers in Integrative Neuroscience, Vol. 3, Article 29, 1-11

Teitelbaum, P., Teitelbaum, O., Nye, J., Fryman, J.& Mauer, R. (1998). Movement analysis in infancy may be useful for early diagnosis of autism. Psychology, 95:23, 13982-13987

Twachtman-Reilly, J., Amaral, S.C. & Zebrowski, P. P. (2008). Addressing feeding disorders in children on the autistic spectrum in school based settings: Physiological and behavioral issues. Language Speech and Hearing Services in Schools, 39, 261-272.

Volkert, V.M. & M Vaz, P.C. (2010). Recent studies on feeding problems in children with autism. Journal of Applied Behavioral Analysis, 43 (1), 155-159.

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Autism Spectrum Disorders: Clinical Parameters of Oral Placement Therapy (OPT)

Posted by Deborah Grauzam on

Authors: Robyn Merkel-Walsh M.A., CCC-SLPSara Rosenfeld-Johnson M.S., CCC-SLP

Foreword:

This article, in the original form, was published in Advance Magazine for Speech Pathologists. The article has been expanded upon and revised with current Evidenced Based Practice.

Abstract:

Autism is a developmental disability that affects, often severely, a person's ability to communicate and socially interact with others. Autism Spectrum Disorder (ASD) impacts 1 of 68 children in the United States (CDC, 2015). In “cluster” states such as New Jersey, as many as 1 in 28 boys are affected. Autism Spectrum Disorders (ASD) is an umbrella term to include related disorders such as Asperger's Syndrome, Pervasive Developmental Disorder (PDD) and Kanner's Syndrome. The intensity of symptoms varies widely; however, all people on the spectrum display impairments in communication, social relationships and patterned behaviors. What is not as clearly understood, is the comorbidity of Oral Placement Disorder (OPD). There is  acknowledgement that, at least in a subpopulation of children with autism, communicative deficits may instead stem from more basic motor and oral motor issues (Belmonte, Saxena-Chandhok , Cherian, Muneer,  George & Karanth, 2013). Therefore, it is important for therapists to evaluate and treat not only the communication deficits with the ASD population, but also the oral sensory-motor deficits that many of these children present with.   

Introduction:

Most individuals with autism are diagnosed by the age of three or younger, and the primary complaint is delayed language skills and/or the regression of language use (Wiggins, Baio & Rice, 2006). For example, parents often report that their child was able to say some words, but suddenly they stopped speaking and became socially withdrawn. At the same time, they began engaging in repetitive behaviors, their play skills regressed, and parents reported poor eye contact and limited socialization with others (CDC, 2015).

When a child is diagnosed with ASD, most likely, a Speech-Language Pathologist (SLP) will be called upon for an evaluation. It is imperative for therapists to look at not only receptive and expressive language, but oral motor skills, oral sensory-motor issues, feeding and motor planning in order to obtain global information that may be impacting the child's ability to communicate. Dr. Barry Prizant, a leader in the field of ASD, has indicated that there is increasing evidence that lack of speech and/or gestures in children with autism may be related to issues other than social-cognitive abilities. Prizant argues that clinical evidence suggests that motor speech impairments can be a significant factor inhibiting the development of speech in children with ASD (Prizant, Wetherby,  Rubin & Laurent, 2010).

Assessment:

In clinical practice, the Speech-Language Pathologist needs to look at several areas in order to devise a treatment plan. This includes 1) sensory processing 2) structure and tone 3) pre-feeding skills 4) feeding skills 5) motor planning and 6) speech sound production.

Sensory processing is important to assess, as it relates to feeding and speech in children with ASD. Acceptance of touch to the face and oral cavity, as well as oral habits such as teeth grinding, mouthing objects and eating items other than foods (PICA) are critical to assess. Some children with ASD are over-responsive to sensory stimuli while others may be under-responsive. An over-responsive child may react to sounds in the kitchen and be distracted during meals, while an under-responsive child may seek pressure in the mouth by chewing on non-edible items (Overland & Merkel-Walsh, 2014).

Structure and tone must be assessed to rule out any comorbid factors that may be impeding feeding and speech. Children with autism may also present with issues such as: dysarthria, Orofacial Myofunctional Disorders, dental malocclusions, or Ankyloglossia. Low-tone occurs in approximately thirty percent of children with ASD (Bailey, 2013). Global hypotonia also occurs with ASD (NAN, 2015). Char Boshart (2015) has carefully designed an Ebook which outlines how to assess oral structures.

Pre-feeding skills are the underlying oral sensory-motor skills that are necessary for safe, effective, nutritive feeding (Overland & Merkel-Walsh, 2013). Morris & Klein (2010) and Overland & Merkel-Walsh, have written texts describing pre-feeding skills with careful detail.

A thorough feeding assessment is a team approach. In addition to the SLP, the feeding team may include the child’s pediatrician, nutritionist, gastroenterologist and/or otolaryngologist. It is important to determine if feeding challenges are organic or behavioral. Feeding disorders in children with ASD are often judged to be behavioral, when there may be medical and/or sensory-motor underpinnings. Most children with self-limited diets have feeding challenges that are multidimensional and are not purely behavioral (Roche, Eicher, Martorana, Berkowitz, Petronchak, Dziob & Vitello, 2011). Children with ASD often have sensory processing issues which impact feeding, but they may also have oral sensory-motor challenges that are related to deficits in pre-feeding skills. An SLP who diagnoses a feeding disorder in ASD must be sure to rule out any related medical etiology such as reflux or food allergies.

Motor planning disorders can also be comorbid with an ASD diagnosis. Childhood Apraxia of Speech (CAS), according to The American Speech-Language-Hearing Association, is a neurological childhood (pediatric) speech sound disorder in which the precision and consistency of movements underlying speech are impaired in the absence of neuromuscular deficits (e.g., abnormal reflexes, abnormal tone). CAS may occur as a result of known neurological impairment, in association with complex neurobehavioral disorders of known or unknown origin, or as an idiopathic neurogenic speech sound disorder. The core impairment in planning and/or programming spatiotemporal parameters of movement sequences results in errors in speech sound production and prosody (ASHA, 2007). In assessing a child with ASD, an SLP must determine if CAS could be a factor in a child being non-verbal. Experts in CAS, such as David Hammer and Deborah Hayden, have done extensive work in the diagnosis of CAS, and standardized measures such as The Kaufman Speech Praxis Test are available to clinicians to diagnose this disorder.

Finally, speech clarity is an important part of the assessment. There are standardized measures available, such as the Goldman-Fristoe Test of Articulation-2; however when assessing a child with ASD, standardized measures may prove challenging. There may also be children who cannot be tested because they are non-verbal. Therapists should not assume that cognition is severely impaired in a non-verbal child with ASD, because there may be coexisting oral-motor issues (Merkel-Walsh, 2014). This is why the aforementioned assessment tools are so important.

Treatment:

After a thorough assessment, the SLP can create a treatment plan that will incorporate: 1) oral sensory-motor based activities 2) feeding therapy 3) Oral Placement Therapy (OPT) and 4) speech sound production.

Oral sensory-motor based activities involve activities designed to regulate the sensory system, help stabilize postural stability, orient towards the midline and establish pre-feeding skills. Massage, vibration, and tactile stimulation methods are often used to stimulate oral postures, improve stability, and improve strength and dissociation (Morris & Klein, 2000). Deborah Beckman has a systematic approach to providing oral sensory-motor therapy called the Beckman Oro-facial Deep Tissue Release©. The protocol uses mechanical muscle responses, which are not mediated cognitively, to baseline the response to pressure and movement, range of movement, variety of movement, strength of movement and control of movement for the lips, cheeks, jaw, and tongue (Beckman, 2014). Therapeutic tools may also assist with sensory-motor and pre-feeding skills. For example, a Jiggler tool can be used to superimpose lip closure, the placement skill needed for bilabial sounds and spoon feeding. Massaging the lateral margins of the tongue can provoke lateralization which is important for safely handling a small bolus (Overland & Merkel-Walsh, 2013).

Therapeutic feeding techniques are necessary for those individuals who require supports to ensure a safe, effective, nutritive feeding (Overland, 2010). Therapeutic feeding involves postural supports, adaptive utensils and cups, placement of the food and supplemental techniques to assist in handling a bolus. It also involves careful consideration of food choices, especially with children on the autism spectrum. Establishing a home base diet is critical in diet-shaping and diet expansion (Overland & Merkel Walsh, 2013). Therapeutic feeding also considers nutrition needs and diet restrictions.

Oral Placement Therapy is a tactile approach to therapy for those individuals who cannot respond to look and me and say what I say. OPT is a modern extension of Phonetic Placement Therapy (Van Riper, 1954) and The Feedback Model (Mysak, 1971). It is based on a very common sequence (Young and Hawk, 1955; Van Riper, 1978). Merkel-Walsh and Roy-Hill (2014) presented this concept at the ASHA Convention:

Facilitate speech movement with the assistance of a therapy tool (ex. horn, tongue depressor) or a tactile-kinesthetic facilitation technique (ex. PROMPT facial cue);

Facilitate speech movement without the therapy tool and/or tactile-kinesthetic technique (cue fading);

Immediately transition movement into speech with and without therapy tools and/or tactile-kinesthetic techniques.

Speech sound production should always proceed oral sensory-motor and OPT tasks. Speech tasks may involve repetition of target words, and may involve tactile cueing such as the PROMPT method (Prompts for Restructuring Oral Musculature Phonetic Targets). PROMPT has been found useful for children with ASD, (Rogers, Hayden, Hepburn, S., Charlifue-Smith, Hall & Hayes, A. 2006). PROMPT is a positive treatment method, as it provides cues for placement for children who cannot easily imitate oral placements for sound production. PROMPT can be used  in conjunction with language goals.

Clinical Parameters:

Once a plan is established and an OPT plan is created, therapists are often challenged by service delivery models, since individuals with ASD often present with challenging behaviors including: self- stimulatory behaviors (e.g. hand flapping or spinning), aggression, non-compliance, work avoidance and inability to attend to task. Since there are many theories on service delivery models in autism, therapists must decide which model best suits their treatment style, and which models are based on research and evidence based. With some background on oral-motor therapy and OPT, therapists know that the child must be seated appropriately in order to gain stability and appropriate positioning for the therapy to be successful. This often presents as a challenge with this population; however with help from ASD experts, it is quite easy to incorporate oral motor and OPT techniques into a therapy plan.

Greenspan, Wetherby and Prizant are advocates of language developing through play schemas in the natural setting. Floor time, modeling and hands-on life experiences are critical in this “child centered” model. Typical natural settings include the home, the park and the grocery store. This approach follows the child's "lead", the direction the child wants to go. The adult engages the child in pleasurable activities with reciprocal play and communicative exchange, so that the activity in itself is reinforcement for the child. The therapist judges what the child wants to do based on non-verbal and verbal cues. This is the basis of the SCERTS model. “SC” - Social Communication – the development of spontaneous, functional communication, emotional expression, and secure and trusting relationships with children and adults; “ER” - Emotional Regulation - the development of the ability to maintain a well-regulated emotional state to cope with everyday stress, and to be most available for learning and interacting; “TS” – Transactional Support – the development and implementation of supports to help partners respond to the child’s needs and interests, modify and adapt the environment, and provide tools to enhance learning (e.g., picture communication, written schedules, and sensory supports). Specific plans are also developed to provide educational and emotional support to families and to foster teamwork among professionals (Prizant, Wetherby, Rubin & Laurent, 2007).

Though the SCERTS is a wonderful model for therapy, the challenge in using this approach with oral sensory-motor and OPT  programs is that the therapy is definitely led by the therapist, the client does not select the activities or tools, because the therapist knows what activities are required to improve a certain muscle-memory based skill (Merkel-Walsh, 2014). The treating SLP must balance the structure needed for OPT programs with a model that fosters a reciprocal communication exchange.

Applied Behavioral Analysis (ABA) is a method of behavioral intervention developed by Ivan Lovaas PhD and Tristan Smith PhD. It consists of teaching skills by breaking them down into small steps, while rewarding the correct responses. It is data driven and quite intensive. ABA is often associated with Discrete Trial Teaching (DTT) which uses the instruction-prompt-response-reward method to help people on the spectrum complete complex tasks. The ABA method has the most empirical research to date to show progress in children on the autism spectrum (CAN, 2005). This approach is better suited to oral-motor therapy, since OPT activities are broken down into small specific steps and have preset mastery levels, such a Bite Blocks, which have a 15 second criteria for mastery. OPT tasks can easily be written into short term objectives (STO) which are the basis of program books for ABA programs. OPT progress can be easily charted and graphed to track progress.

LG Rethink Graph

Graph provided by www.rethinkfirst.com.

Therapists do not have to choose between these two models; both principles can be applied if therapy sessions are carefully planned. A challenge in following the child-centered approach is that OPT programs have pre-established hierarchies and set requirements for mastery or success; however, one must consider that therapy must be rewarding in order for the child to engage. Children on the spectrum will need consistent, highly-motivating tangible reinforcers to engage in OPT. In addition, the sessions need to be language oriented as the main goal is oral communication.

With these principles in mind, here are general parameters in structuring Oral Placement Therapy with children presenting with ASD:

• Create a calming environment ensuring that lighting and sound have been considered in relation to sensory processing issues. Meta-music, a lava lamp, or concentration tapes can all help make the session more calming and rewarding. Consult with an Occupational Therapist if a child with ASD presents with very intense sensory dysregulation.

• Select an appropriate setting that encourages 90 degree angles in the hips, knees and ankles. Make sure the feet are on the floor or flat on an elevated surface, such as the foot rest of a high chair. You may use dycem on the chair so the child does not slide, or may need additional weighted items, such as a rice bag across the lap or a weighted vest, to give additional sensory input. If this is not possible due to out of seat behavior, a Behaviorist will need to intervene prior to therapy sessions and help the SLP with a behavior plan and/or use of alternative seating such as a bean bag chair, swing and or a ball pit.

• Create a picture schedule booklet for the client or schedule board from start to end with every activity and built in breaks for gross and sensory-motor play. Ensure that you are using favorite items, sound activities toys, music, and sensory based activities for free play on breaks. This builds in Greenspan's philosophies while keeping within the structured parameters of an ABA format.

• In coordination with an ABA Therapist/Behaviorist, create a token board with a set reward for positive work. For example, 5 pennies can result in a pretzel or squish toy. It also helps to take a photo of the child engaged in the target behavior, such as sitting in a chair with "quiet hands.” Verbalize the target behavior consistently and avoid talking about the negative behavior such as "no spitting" or "stop that." Use positive verbal cues such as, "good sitting with hands down.”

• When using food reinforcers, coordinate this with feeding therapy. For example, a specific placement of a strip to the molars, as where the food is placed in the mouth impacts the skills used to break it down. Use a highly desirable drink, such as fruit juice, with a target straw from the TalkTools® Hierarchy.

• A therapy protocol should always incorporate sensory activities (Sensory Bean Bags, vibration, massage, ZVibe),  jaw activities (Bite Blocks, Jaw Exerciser, Chewy Tube etc.), respiration and phonation activities (Horns, bubbles) and additional OPT activities as needed (Lip Press, etc.). The session should always include sound drills, word imitation (verbal ims) and/or play with targeted words embedded within the structured activity.

• For many kids with ASD, the speech therapist will be involved with sensory-based food tasting programs which can be presented in a discreet trial teaching (DTT) model. First, the child needs to tolerate the new food in their proximity, then touch it, smell it, tolerate it near the mouth, kiss it/tongue touch, hold it in the mouth, chew it and swallow. These steps need to be broken down into small tasks that are highly reinforced.

• Create an OPT book with specific therapy and chart notes, so that the work is done at home and at school/clinic. The therapist must train the parent, or in some cases the babysitter or ABA therapist, so that the exercises are done daily. This is not to say that an ABA therapist should be performing speech therapy, but rather facilitate progress by practicing specifically assigned homework. In some cases, challenging behaviors are much easier for a ABA therapist than for the parent. In addition, parents can videotape sessions to follow at home. Video modeling is a very common procedure in ABA programs.

• Since the main goal is expressive communication, it is imperative that the therapist recognizes the clients strengths in terms of jaw-lip-tongue dissociation and planes of movement as taught by Debra Hayden's PROMPT System Hierarchy, Nancy Kaufman’s “Kaufman Praxis Level 1” and Lori Overland's/Sara Rosenfeld-Johnson's oral motor developmental norms references. This will help the speech therapist select the first words for drill and repetition in order to translate muscle-motor memory into speech production. For example, if the child's lip closure is a goal, and he/she is working on TalkTools® horn level 1, simple CV, VCV, VC words with picture cards should be used to elicit productions such as: me, bee, apple (ae-po), up and so forth. The words should be practiced in every session with the help of facial cues (PROMPT), and lip reading cues to 80% mastery. When this occurs, the therapist can then fade cues and move to higher level targets such as CVC forms.

• To evoke new productions spontaneously, David Hammer, an expert in the field of apraxia, recommends use of repetitive games and toys within each session. For example, if target words are in/out use a simple activity, such as small animals that go in and out of a paper towel tube, and repeat this each session so that the client can predict what utterances are expected. Prediction of outcome reduces anxiety and also follows along with Dr. Edythe Strand's research on the need for repetition in order to solidify a motor plan.

Conclusion:

In summary,  OPT for children with ASD is an essential part of their speech therapy program in addition to pragmatics, language, sensory integration and total communication. While engaging children with ASD may be challenging, if speech therapists follow the lead of experts in the field of autism, OPT is actually quite easy to deliver as long as the therapist combines the principles of behavior modification with natural language development. Since OPT hierarchies are very task oriented and data driven, (e.g., each TalkTools® horn has a pre-established criteria for mastery), therapists can present activities in specific sequences with consistent positive reinforcers which is in line with the experts suggestions for systematically teaching target behaviors in an ABA format, while the SCERTS approach opens pathways for carryover and language acquisition with improved speech clarity.

Click here to learn more about the course Robyn Merkel-Walsh teaches on Autism & OPT



Robyn_color_lowRobyn Merkel-Walsh MA, CCC-SLP is a speech pathologist with over 20 years of experience in both the Ridgefield Public Schools, and in her private practice located in Bergen County, NJ. She is the author of The Smile Program, A Sensory Motor Approach to Feeding, and other educational materials. Robyn is a certified TalkTools Instructor on Tongue Thrust, Autism and Oral Placement Therapy. Robyn is the acting chair of the Oral Motor Institute. She can be reached at robynslp95@aol.com.

   

Sara R JSara Rosenfeld-Johnson MS, CCC-SLP is the founder of Innovative Therapists International, and TalkTools® based in Charleston, South Carolina. She is the author of Oral Placement Therapy (OPT) for Speech Clarity and Feeding, The HOMEWORK Book, Assessment and Treatment of the Jaw, OPT for /s/ and /z/ as well as many other education materials.  Sara specializes in assessment and treatment of motor speech and feeding disorders.  She is a national and international speaker on the topic of Oral Placement Therapy.  She can be reached at srjohnson@talktools.com.

Thanks to Rethink for providing the graph above. 

REFERENCES

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Rogers, S. J., Hayden, D. Hepburn, S., Charlifue-Smith, R., Hall, T., & Hayes, A. (2006). Teaching young nonverbal children with autism useful speech: A pilot study of the Denver Model and PROMPT interventions. Journal of Autism and Developmental Disorders, 36(8), 1007–1024.

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